Explanatory models of somatoform disorder patients attending a psychiatry outpatient clinic: A study from North India

Abstract

Background:

The symptoms of somatoform disorders are very distressing to the sufferer as well as pose significant burden on the health-care delivery system. Although the nature of symptoms is physical, the underlying mechanisms are not clearly understood.

Objective:

The purpose of this study was to assess the explanatory models of patients with somatoform disorders presenting to a tertiary care hospital in Northern India.

Method:

A total of 99 consecutive adult patients (≥18 years) with diagnosis of somatoform disorders according to the International Classification of Diseases–10th Revision (ICD-10) were evaluated for their explanatory models using the causal models section of Explanatory Model Interview Catalogue (EMIC).

Results:

The mean age of the study sample was 36.52 years, and the mean duration of illness was 59.39 ± 57.68 months. The most common clinical diagnosis was that of persistent somatoform pain disorder. The most common explanations given belonged to the category of psychological factors (68.7%) followed by weakness (67.7%), social causes (51%) and karma–deed–heredity (53.5%) category. The mean number of etiological categories reported were 2.6 (standard deviation (SD) = 1.7). Among the various specific causes, the commonly reported explanations by one half of the sample in decreasing order were general weakness (63.6%), mind–thoughts–worry category (59.6%) and loneliness (53.5%). The mean number of specific etiologies was 4.9 (SD = 3.83).

Conclusion:

Most of the patients with somatoform disorder attribute their symptoms to psychological factors. It also becomes imperative to understand the physical symptoms in somatoform disorders from the sociocultural aspects of patients.

Keywords

Somatoform disorder pain explanatory models

Introduction

The expression of emotional distress in the form of somatic symptoms is common in all cultures across the world. However, studies have shown that patients experiencing emotional problems from non-Western countries more frequently present with somatic symptoms (Gureje, Simon, Ustun, & Goldberg, 1997; Hammond, 1964; Kirmayer & Young, 1998; Simon, Gater, Kisely, & Piccinelli, 1996; Simon & Gureje, 1999). Many terms have been used in the literature to label these somatic presentations, which include ‘medically unexplained symptoms’, ‘somatization’, ‘unexplained symptoms’, ‘idiopathic somatic complaints and syndromes’ and others (Escobar & Gureje, 2007). Of all the patients presenting with somatic symptoms, a group of patients are diagnosed as having somatoform disorders.

Patients suffering from somatoform disorders put a lot of burden on the health-care system in form of repeated consultations and investigations. These patients have a poor quality of life as well as are challenging to the doctor who provide care disproportionate to the disease, which most of the times is ineffective (Barsky, Orav, & Bates, 2005; Smith, Monson, & Ray, 1986; Stanley, Peters, & Salmon, 2002; Sumathipala, Hewege, Hanwella, & Mann, 2000). The interpretation of the somatic symptoms by an individual to be of physical nature leads to difficulty in recognizing the psychological symptoms or psychiatric disorders like depression and anxiety disorders (Skapinakis & Araya, 2011).

A possible reason for consulting various physicians and non-mental-health professionals is the difference in the explanatory models held by the patients and the physicians. Hence, it is important for the mental health professionals to be aware about the explanatory models held by the patients of somatoform disorders, so that these are also addressed while providing care to these patients.

Very few studies have evaluated the explanatory models of the patients presenting with unexplained physical symptoms. Hiller et al. (2010) compared 79 patients with somatoform disorders with 187 chronic pain patients for the perceived explanatory models of their symptoms by using Causal Attributions Interview. Patients with somatoform disorder attributed their symptoms to the categories of mental/emotional problems (46.9%) and somatic diseases (41.1%), and the mean number of causes reported was 2.57. However, the patients suffering from chronic pain attributed their symptoms to physical overloading/exhaustion (51.6%), daily hastiness/time pressure (41.7%), somatic disease (39.6%) and weather influence (39.0%) and the mean number different attributions was 3.86. Rief, Nanke, Emmerich, Bender, and Zech (2004) assessed the causal illness beliefs of 233 patients with unexplained physical symptoms and reported that patients with somatoform disorders scored high on the illness attribution factors of ‘vulnerability’ and ‘organic causes’, and higher number of symptoms were associated with more number of causal attributions. The patients with somatoform disorder and comorbid depression or anxiety disorders reported more of the psychological causes than patients without comorbidities. Furthermore, the patients with somatoform pain disorders reported fewer psychological attributions for their symptoms compared to those diagnosed with somatization disorder and undifferentiated somatoform disorder. Another prospective study (Henningsen, Jakobsen, Schiltenwolf, & Weiss, 2005) assessed the explanatory models perceived by 186 patients presenting with medically unexplained somatic symptoms in two tertiary care hospitals by using locally adapted version of Explanatory Models of Illness Catalogue (EMIC). It was observed that patients with somatoform disorders attributed their symptoms more frequently to organic causes (80.4%) than the psychosocial causes (19.6%). Furthermore, the patients with somatoform disorders with comorbid depression or anxiety disorders attributed their illness more to the psychosocial factors (56.1%) than the organic etiologies (43.9%). In a larger study from Santiago (Skapinakis & Araya, 2011), 3,807 participants experiencing somatic symptoms in past 7 days were asked to attribute their symptoms to one of the four options, that is, physical illness, mental health problem, both or other causes for their somatic symptoms. The results showed that causal attributions of somatic symptoms were more often of a physical nature. About one-third of subjects with somatic symptoms (n = 1,370) considered their symptoms to be due to psychological causes. However, in the subgroup of subjects with psychiatric morbidity and somatic symptoms (n = 497), about half of the participants attributed their symptoms to psychological reasons. The subjects with somatic symptoms who attributed their symptoms to psychological or mixed etiologies were more likely to be suffering from psychiatric disorder, which was significantly different from those subjects with somatic symptoms and physical attributions.

However, the data are limited with regard to explanatory models held by patients with somatoform disorders from developing countries. A study from Sri Lanka (Sumathipala et al., 2008) assessed the illness beliefs of 68 patients with medically unexplained symptoms by using the Short Explanatory Model Interview (SEMI) (Lloyd et al., 1998) and reported that majority of patients were unable to name their illness (59%) and give any cause (56%) for the same. On the consequences domain, 95% of participants expressed significant worries, 37% believed that symptoms indicated a moderately serious illness and another 58% considered that their symptoms indicated very serious illness. One-third of patients reported fear of death, 20% feared impending paralysis and 13% expressed fear of developing cancer and rest considered that their symptoms indicated unspecified incurable illness. Only a minority of subjects expected any investigation or diagnosis (8.8% for each).

There have been few studies from India which assessed the causal attributions of patients with common mental disorders (Andrew, Cohen, Salgaonkar, & Patel, 2012; Nambi et al., 2002; Pereira et al., 2007; Shankar, Saravanan, & Jacob, 2006), but research in somatoform disorders is lacking. In this background, this study aimed to assess the illness beliefs of patients suffering from somatoform disorders presenting to a tertiary care, multispecialty hospital in North India.

Methodology

The study was carried out at the Department of Psychiatry of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, which is a multispecialty teaching tertiary care hospital providing service to a major area of North India. This department is a general hospital psychiatric unit with both inpatient and outpatient facilities. Many of the patients evaluated in the outpatients are referred for psychiatric consultation from different medical and surgical specialties after being evaluated thoroughly for medical and surgical problems.

All the patients were recruited after obtaining written informed consent. The ethical clearance for the study was obtained from the institute review board. The assessment of explanatory models of somatoform disorders is one of the components of the larger study, and these patients were also evaluated for symptom profile, pathways to care, prevalence and typology of functional somatic symptoms, somatosensory amplification and alexithymia. In this article, only data with respect to explanatory attribution of somatoform symptoms are presented.

Sample

The sample comprised consecutive patients attending the walk-in-clinic of psychiatry outpatient facility during the period of March 2012 to June 2012. The inclusion criteria for the study were age ≥18 years and a diagnosis of somatoform disorders according to the International Classification of Diseases–10th Revision (ICD-10) based on a semi-structured interview. However, those with mental retardation and organic brain syndromes were excluded.

Instruments

Belief about the etiologies was assessed using the explanatory model list described as part of the EMIC (Weiss et al., 1992). EMIC was designed to elicit patient’s attributions of their presenting complaints, their previous help-seeking behavior (including visiting a temple, a traditional healer, or a doctor), their causal models (e.g. previous deeds/karma, evil spirits, punishment by god, black magic, or disease) and perceived consequences (change in the body or mind). In EMIC, the causal models section consists of a list of 50 possible causes that are divided into 10 categories. Additionally, there are two other categories described as ‘others’ and ‘can’t say’. For this study, the list of causal models described as part of EMIC was used to elicit causal models, and data were collected only in quantitative form. The patients were encouraged to give as many reasons as possible for their symptoms spontaneously. Later, they were asked questions specifically eliciting various etiological categories described as part of EMIC. A standard list of questions was made to conduct the initial part of these interviews and to standardize the interview for all patients. Probing was done initially by open-ended questions and depending on the responses, further questioning was conducted, and close-ended questions were used in the end of the interview. Response to etiology categories included in EMIC was recorded as to ‘yes/no’ based on spontaneous reporting of the patient. Then the further interview was carried out to cover all the etiological categories included in EMIC, and the responses were recorded as ‘yes/no’ for each category and among all the ‘yes’ responses, patient was asked to rate one of the response as the most important cause.

Statistical Package for the Social Sciences-14 (SPSS-14, 2005, Chicago, IL, USA) was used to analyze the data. Mean and standard deviation with range was calculated for continuous variables, including sociodemographic and clinical variables. Descriptive analysis was computed in terms of frequency and percentages for discontinuous sociodemographic variables, clinical variables and EMIC. Comparisons were done by using chi-square test and t-test.

Results

During the study period of 4 months, 2,844 new patients were evaluated in the psychiatry outpatient facility, of whom 102 were less than 18 years of age. Of the total eligible subjects, 227 were diagnosed with different somatoform disorders by a qualified psychiatrist. Of these, 117 patients could be approached for the informed consent, and of whom, 103 patients provided informed consent and were recruited for the study. However, four patients did not complete all the assessments for the study. Hence, the final study sample was of 99 patients.

Sociodemographic and clinical profiles

In the study sample, females (n = 60, 60.6%) outnumbered males (n = 39, 39.4%). The mean age of the study sample was 36.52 (standard deviation (SD) = 10.32) years. Most of the patients (n = 87, 87.9%) were married, and more than two-third were Hindu (n = 76, 76.8%); more than half of the sample belonged to the non-nuclear families (n = 54, 54.5%) and was educated upto or beyond high school (n = 55, 55.5%), and most of the participants (n = 60, 60.6%) were home makers/unemployed. Slightly more than two-third were from rural localities (n = 67, 67.7%). Those employed were mostly doing skilled/semiskilled work/unskilled work (n = 23, 23.2%) or were working as clerks/shop owner/farmers (n = 14, 14.1%) and very few were professional/semi-professional (n = 2, 2%).

Clinical profile

The most common diagnosis as per ICD-10 was of persistent somatoform pain disorder (n = 51, 51.5%), followed by undifferentiated somatoform disorder (n = 22, 22.2%) and hypochondriacal disorder (n = 11, 11.1%). A total of 10 patients (10.1%) had somatization disorder, and 2 (2%) suffered from somatoform autonomic dysfunction. Three patients (3%) did not fit into the aforementioned categories of somatoform and therefore were diagnosed with other/unspecified somatoform disorder. The mean age at onset of illness was 30.46 (SD = 9.34) years, and the mean duration of illness was 59.39 (SD = 57.68) months. A total of 33 patients (33.3%) had a comorbid psychiatric disorder in form of dysthymia (n = 1, 1%), major depressive disorder (n = 11, 11.1%), recurrent depressive disorder (n = 2, 2%), anxiety not otherwise specified (NOS) (n = 14, 14.1%), generalized anxiety disorder (n = 1, 1%) and mixed anxiety disorder (n = 4, 4%). A total of 14 patients (14.1%) had a comorbid physical disorder which was not sufficient to explain the type of and extent of physical symptoms, which the patients were experiencing. Only one patient met the dependence criteria for tobacco, although substance use (tobacco and alcohol) was reported by 11 (11%) participants. A total of 91 patients (91.9%) had consulted a physician before presenting to the psychiatrist and slightly more than half (n = 54, 54.5%) had sought help from faith healers for their current set of symptoms at some point of time during the course of their illness. More than half of the patients (n = 57, 57.6%) reported that they abused pain killers to get relief from their symptoms and nearly one-fourth (23.2%) acknowledged that they abused benzodiazepines. Most of the patients (n = 82, 82.8%) had undergone some kind of physical investigation during the course of their illness, and about three-fifth of them (n = 60, 60.6%) still requested for further physical investigations. More than half (n = 52, 52.5%) of the patients desired that they should undergo proper physical examination and most of the patients (n = 81, 81.8%) believed that they required some form of medications.

Explanatory models

When asked to give explanations for their symptoms, most of the patients (n = 85, 85.9%) spontaneously reported at least one explanation for their symptoms. The most common explanation given by the patient could be categorized into psychological causes (n = 67, 67.7%), and other details are shown in Table 1. More than half of the patients (54% of the total sample) gave both psychological causal models and also the weakness model. The mean number of explanations spontaneously given by the participants was 4.9 (SD = 3.83), while on probing the number of explanations increased to 6.16 (SD = 4.38). However, when probed about specific etiologies about their illness, 96% of subjects reported at least one cause of their illness, and four patients still did not mention any cause for their symptoms. The most common explanations given were in the form of psychological causes (68.7%) followed by weakness (67.7%), social causes (51%) and karma–deed–heredity (53.5%) category. The mean number of etiological categories reported on probing were 2.6 (SD = 1.7). Among the various specific causes as assessed by EMIC, the commonly reported explanations by half of the participants in decreasing order were general weakness (63.6%), mind–thoughts–worry category (59.6%) and loneliness (53.5%). About three-fifths (59.6%) gave both psychological causal models and also the weakness model. The mean number of specific etiologies were 4.9 (SD = 3.83).

Table 1.

Perceived causes/explanatory models of somatoform disorders.

Causes	Spontaneously reported number (%)	Reported on probing number (%)
No explanations reported	14 (14.1%)	4 (4%)
Reported at least one cause	85 (85.9%)	95 (96%)
Ingestion	13 (13.1%)	27 (27.3%)
Health–illness–injury–medical	18 (18.1%)	27 (27.3%)
Weakness-nerves	63 (63.6%)	67 (67.7%)
Social causes	48 (48.5%)	51 (51.1%)
Psychological	67 (67.7%)	68 (68.7%)
Victimization-abuse	2 (2%)	2 (2%)
Sexual–reproductive functions	3 (3%)	4 (4%)
Karma–deed–heredity	30 (30.3%)	53 (53.5%)
Traditional	2 (2%)	4 (4%)
Environment–sanitation	11(11.1%)	11 (11.1%)
Others	1 (1%)	0 (0%)

Comparison of causal attributions of study subjects

Diagnosis

When assessed for differences in the reporting of explanatory models between subjects diagnosed with persistent somatoform pain disorder and other somatoform disorder categories, significant difference was found on the reporting of ‘anatomical-physical problems’ (other somatoform disorders (n = 48, 95.83%) vs persistent somatoform pain disorder (n = 42, 82.35%); χ² value = 4.550; p = .033) and personality difficulty (persistent somatoform pain disorder (n = 51, 100%) vs other somatoform disorders (n = 43, 89.6%); χ² value = 5.595; p = .018) as an explanatory model.

Gender

Certain differences were noted between the two genders with regard to the explanations for their illness. Significantly higher proportion of males (n = 18, 46.15%) reported explanations categorized into ‘ingestion category’ (46.15% vs 15%; χ² value = 12.59; p = .006). Some of the male subjects attributed their symptoms to use of alcohol (n = 9, 23.07%) and smoking (n = 8, 20.51%), whereas none of the female participants did so, and this difference between the two genders was statistically significant (for smoking χ² value = 15.231, p < .001, and for alcohol χ² value = 13.390; p < .001).

Religiosity

Maximum numbers of differences were seen in the explanations given by those belonging to Hindu religion and those belonging to non-Hindu religion. The patients belonging to religions other than Hinduism reported more explanations from health (non-Hindus = 9, 39.13% vs Hindus = 18, 23.68%; χ² value = 12.429; p = .053) and social cause (non-Hindus = 16, 69.56% vs Hindus = 35, 46.05%; χ² value = 24.431; p = .002) categories of EMIC. When each explanations were compared between Hindus and non-Hindus, significant differences were found for the explanations of prior illness (non-Hindus = 6, 26.08% vs Hindus = 3, 3.94%; χ² value = 10.758; p = .005), prior treatment (non-Hindus = 6, 26.08% vs Hindus = 9, 11.84%; χ² value = 8.502; p = .014), family problems (non-Hindus = 11, 47.82% vs Hindus = 19, 25%; χ² value = 12.590; p = .002), marital problems (non-Hindus = 7, 30.43% vs Hindus = 5, 6.57%; χ² value = 14.676; p = .001), work problems (non-Hindus = 10, 43.47% vs Hindus = 27, 35.52%; χ² value = 9.197; p = .010), other interpersonal problems (non-Hindus = 8, 34.78% vs Hindus = 17, 22.36%; χ² value = 8.362; p = .015), bereavement (non-Hindus = 4, 17.39% vs Hindus = 2, 2.63%; χ² value = 10.150; p = .006), financial stress (non-Hindus = 12, 52.17% vs Hindus = 20, 26.31%; χ² value = 7.658; p = .022), semen–vaginal fluid (non-Hindus = 2, 8.69% vs Hindus = 0; χ² value = 9.186; p = .010), bad deeds (non-Hindus = 6, 26.08% vs Hindus = 12, 15.78%; χ² value = 6.198; p = .045) and neglected vows or rituals (non-Hindus = 2, 8.69% vs Hindus = 3, 3.94%; χ² value = 13.886; p = .001).

Locality

Significant differences were found in the reporting of seminal–vaginal fluid (n = 2, 6.25% vs n = 0; χ² value = 4.274; p = .039) and environmental pollution (n = 4, 12.50% vs n = 0; χ² value = 8.728; p = .003) as explanation for their symptoms; these were more commonly by patients from urban locality.

Education

When the patients with education less than high school were compared for their etiological explanations from those with higher education, significant differences were found in the reporting of fate/chance (n = 19, 35.84% vs n = 8, 17.39%; χ² value = 4.230; p = .040) and will of God (n = 24, 45.28% vs n = 11, 23.91%; χ² value = 4.921; p = .027) reported more commonly by those with lesser years of education. The subjects with more than high school education reported bereavement as an etiological model more frequently (n = 6, 13.04% vs n = 0; χ² value = 7.359; p = .007).

Comorbidity

One-third of the participants had a comorbid psychiatric disorder. When the patients with comorbid psychiatric disorder (n = 33, 33.33%) were compared from those without comorbidity (n = 66, 66.66%), significant differences were found in the explanatory models. Patients with comorbid psychiatric disorder more frequently attributed their symptoms to weakness-nerves (81.81% vs 60.6%; χ² value = 7.436; p = .039), social causes (72.72% vs 40.9%; χ² value = 21.119; p < .001) and psychological causes (87.87% vs 59.09%; χ² value = 17.094; p = .004).

Correlations

The age of onset and duration of illness were not significantly correlated to the mean number of etiological explanations given spontaneously (r = −.003 and .153, respectively) or on probing (r = −.085 and .202, respectively).

Discussion

This study evaluated the perceived etiological models held by the patients suffering from somatoform disorders who attended the outpatient clinic of a tertiary care psychiatric facility in the northern part of India. The study included 99 consecutive patients who consented to be the part of this research. When asked to report spontaneously and on probing, the etiological causes reported most frequently were categorized into psychological factors. The second and the third most common explanations reported spontaneously were related to the weakness (in general and that of nerves) and social factors. On probing, besides psychological factors, the common etiological models were weakness (in general and that of nerves), karma–deed–hereditary and social factors categories. Most of the patients had more than one explanatory model with mean number of explanations being 6.2.

As there is lack of consensus in the literature, findings of this study support some of the earlier reports but are slightly different from other reports. Studies which have evaluated patients with somatoform disorder/those with medically unexplained symptoms have reported that 43.9%–80.4% attribute their symptoms to the organic causes and 11%–56.1% attribute symptoms to the category of mental/emotional problems or psychosocial/psychological causes (Henningsen et al., 2005; Hiller et al., 2010; Nambi et al., 2002; Patel, 1995; Skapinakis & Araya, 2011).

If one tries to compare the findings of this study, psychological factors reported in this study can be considered as equivalent of mental/emotional problems and the weakness (in general and that of nerves) can be considered as equivalent of somatic diseases. However, when one tries to look at these findings in terms of percentage of patients reporting the organic causal model, findings of this study are in the range reported in the literature. However, it is important to note that the range reported in the literature is quite wide and is possibly affected by factors like treatment setting from which the patients were recruited. In this study, patients were recruited from psychiatric outpatient facility of a tertiary care hospital in which patients have a lot of freedom to choose whom to consult and whom not to consult, with no organized in-built referral system as part of health-care agencies. In contrast, in one of the earlier study, patients were recruited from a behavioral medicine inpatient unit from Germany (Hiller et al., 2010), in which there is much better organization in the health-care system with appropriate referrals. Other studies have evaluated primary care attendees (Patel, Pereira, & Mann, 1998). However, in this study, about two-thirds of the patients attributed their symptoms to psychological causes. Besides cultural variations, significantly higher proportion of patients attributing their symptoms to psychological causes may be a reflection of the organization of services and help-seeking behavior in our setting. It is also quite possible that in our setup, many patients who are referred from other specialties to psychiatry services, do not attend the same because of stigma. So, higher percentage of those with psychological and social causal models in addition to the organic model (reflected by general weakness and weakness of nerves) does report to psychiatry services. This may possibly explain higher prevalence of the psychological models, and a higher percentage of patients have both psychological and weakness explanatory models in our setting. Although the assessment instruments were different in both the studies, the mean number of explanations reported by patients in this study (2.6 vs 2.57) and in the study from Germany (Hiller et al., 2010) reflects that across different cultures and treatment settings, patients do hold more than one explanation for their symptoms.

In this study, patients with comorbid psychiatric disorder more frequently attributed their symptoms to weakness-nerves, social causes and psychological causes. This is similar to the finding of earlier studies, in which the patients with somatoform disorder and comorbid psychiatric disorders more frequently reported psychological causes than patients without comorbidities (Rief et al., 2004; Skapinakis and Araya, 2011).

In this study, slightly more than half of the patients reported ‘karma–deed–heredity’ as the causal models for their symptoms. Patients with other psychiatric disorders like depression and obsessive compulsive disorder from India too attribute their symptoms to the same (Grover et al., 2012; Patra, in press). This category includes causes like fate/chance, bad deeds, heredity, will of god, evil eye, sorcery, possession, neglect vows or rituals, astrology and other supernatural causes. This possibly reflects the cultural influence on the causal models held by patients with various psychiatric disorders in Indian setting. The personality structure of an Indian is in general understood as dependence prone, traditional and religious (Varma, 2009a, 2009b). According to the law of karma as understood in Hinduism, every event is both a cause and effect, and the basic philosophy is ‘as you sow, so shall you reap’. Another influence of culture was reflected by significant difference in various etiological models held by those belonging to Hindu religions and those belonging to non-Hindu religion in this study.

In this study, in general, the sociodemographic variables (except for religion) and duration of illness did not have significant influence on reporting of various explanatory models, suggesting that the explanatory models held by patients are not influenced by these factors.

To conclude, this study suggests that patients of somatoform disorders attending the psychiatric outpatient services hold multiple explanatory models. This study refutes the notion that the patients with somatoform disorders predominantly have organically oriented illness models. Furthermore, our findings suggest that the presence of comorbid diagnosis of anxiety or depressive disorder increases the attribution of symptoms to organic causes, psychological causes and social causes too. Furthermore, this study suggests that culture has significant impact on the explanatory models with half of the patients attributing their symptoms to karma and deeds. All these findings can have important management implications. First, the mental health professionals should understand that many of the patients with somatoform disorders do hold explanatory models, which are not much different than those considered to be responsible by clinicians themselves. Hence, they should explore about the same and wherever possible should validate the nonorganic explanatory models held by the patients. Next, wherever possible, the clinicians should use the karma theory to change the patient for betterment.

The results of this study must be interpreted in the light of the fact that the study was limited to a population attending the outpatient clinic of a tertiary care hospital. However, it is important to remember that many patients attending primary care services or general medical outpatient services may actually hold different explanatory models and actually do not attend the psychiatric services due to stigma. Hence, the findings cannot be generalized to general population per se. It would be worthwhile in future to compare the explanatory models held by patients with somatic symptoms and attending the primary care or general medical outpatient and compare them with those attending the psychiatric outpatient services. This study was limited to about 100 patients. Analysis was carried out by using multiple chi-square tests, which can lead to type 1 errors. Future studies need to evaluate larger samples which can further help in generalization of the present findings.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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